Calhoun Convalescent Center
Calhoun Convalescent Center in Saint Matthews, SC — inspection on March 26, 2025.
Found 7 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
also had another room with a roommate and this was the problem.
She confirmed R80 urinates in the
room was very offensive with terrible odor and gnats throughout.
She also confirmed he cannot have regular meal trays in his room, he uses disposables.
Interview on 03/23/25 at 2:14 PM, Certified Nursing Assistant (CNA)1 confirmed R80 was her resident and said she'd been in the room.
She said she did not walk over to where the feces and urine were all over the right side of the room.
She confirmed he always get disposable trays because he will not return the regular dishes and silverware.
She said he will try to hit you if you try to help him with getting cleaned up.
She confirmed his room had a terrible odor and the odor could be smelled from down the hall.
Interview on 03/24/25 at 10:30 AM the DOH stated, we will do a deep clean of everything in E-2 [R80's room] since he is in the hospital.
Interview on 03/25/25 at 10:07 AM, the Administrator stated, housekeeping should go in, wipe down bedside drawers and table, and we have a deep cleaning schedule. We try to hit all the rooms in that quarter.
She tries to get 8-10 rooms some weeks.
They sweep, mop, empty the trash, sweep/mop in the bathrooms. R80 goes through these cycles, where he is fixated that someone is going to pick him up to take him home. He will not let anyone near him. He will barricade himself in his room.
They ask every day if they can clean his room, give him a shower, dress him.
Residents have a right to refuse services. He won't let us clean, defecate and urinate on the floor.
When he is escalated, they will serve him his meals in Styrofoam disposable. He is very territorial. He needs a Dementia Unit. We send email referrals out to try to find placement for him. He urinates in the fan. He won't use the bathroom when he's in that cycle.
She agreed the room still needed to be cleaned every day.
425170 03/26/2025
Calhoun Convalescent Center 601 Dantzler Street Saint Matthews, SC 29135
Record review of R107's Point of Care History ADLs Type of Bath? section revealed the following
-03/23/25 - no documentation charted for this date -03/24/25 - no documentation charted for this date -03/25/25 - no documentation charted for this date -03/26/25 at 2:55 PM -partial bed bath Record review of R107 Point of Care History ADLs What is the resident's level of bladder function? section revealed the following documentation: -03/23/25 at 1:51 AM - incontinent -03/24/25 at 1:52 AM and 10:30 PM - incontinent -03/25/25 at 10:25 PM -incontinent -03/26/25 at 1:18 AM, 2:55 PM - incontinent; at 7:57 PM - continent Record review of R107 Point of Care History ADLs What is the resident's level of control with bowel function? revealed the following documentation: -03/23/25 at 1:51 AM - incontinent -03/24/25 at 1:52 AM and 10:30 PM - incontinent -03/25/25 10:25 PM - incontinent -03/26/25 at 1:18 AM, 2:55 PM, and 7:57 PM - incontinent An interview on 03/25/25 at 1:25 PM with the Administrator and Director of Nursing (DON) revealed, their expectation is that when a staff member see's a resident call light is on is to answer the call light and complete the resident's request prior to turning off the call light.
The Administrator further stated that if the staff member that first see the resident call light is not able to answer the resident's request (CNA answer's call light but the resident requested medication) then the call light should remain on until the appropriate staff person can assist the resident.
An interview on 03/26/25 at 2:16 PM with LPN5 revealed, they were informed of the situation that occurred on 03/25/25 with R107. LPN5 further revealed that staff ignoring the resident's request to be provided with ADL care in a timely manner is considered neglect. LPN5 finally stated, CNA4 was the resident's assigned CNA for 03/25/25 and is now placed on the Do Not Return list for the facility.
425170 03/26/2025
Calhoun Convalescent Center 601 Dantzler Street Saint Matthews, SC 29135
During observation resident had a difficult time determining how much grits and eggs were on his tray.
Grits were observed on the side of the resident's face and on his clothing protector and his tray. R41 stated that he asked staff for assistance, but staff became argumentative with him and told him that he could feed himself.
An observation and interview on 03/25/25 at 7:37 AM with Certified Nursing Assistant (CNA)4 and LPN1 revealed them at the nursing station and having a personal conversation.
During interview with CNA4 and LPN1 both stated that the R41 could feed himself. CNA4 stated they were not the resident's assigned CNA for the day but volunteered to assist the resident.
Further interview with LPN1 revealed that the resident can feed himself but does require staff assistance. LPN1 finally stated that R41 does not have care plan interventions related to his hand injury or assistance with meals due to his injury.
An observation on 03/26/25 at 9:04 AM revealed R41 feeding himself his breakfast meal tray with difficulty.
An interview on 03/26/25 at 12:47 PM with the Dietary Manager (DM) and Registered Dietitian (RD) revealed R41 should be assisted with meals.
Therapy attempted to work with the resident after R41 injured his hand but was unsuccessful.
Further interview revealed R41's care plan had not been revised to reflect a change of condition with the resident's ability to feed himself.
An interview on 03/26/25 at 1:05 PM with the Director of Rehabilitation (DOR) revealed R41 received Occupational Therapy (OT) shortly after he injured his dominant hand.
During OT there were attempts to have the resident use his right hand for meals, but it was unsuccessful.
The DOR finally stated that the resident does require assistance with meals and was unable to locate care plan interventions related to this change of condition.
An interview on 03/26/25 at 4:01 PM with the Director of Nursing (DON) revealed they would have expected the resident's care plan to have been revised to reflect his change of condition.
425170 03/26/2025
Calhoun Convalescent Center 601 Dantzler Street Saint Matthews, SC 29135
administered according to physician orders for 1 of 2 residents reviewed for tube feeding.
Resident
intellectual disabilities, gastrostomy, schizophrenia and anxiety, The facility policy on Physician Orders, revised May 5, 2023, states The qualified nurse will obtain and transcribe orders according to Facility Practice Guidelines, .PRN (as needed) medications: Transcribe or electronically enter all PRN Medication/Treatment Orders to properly identified area of MAR (medication administration record).
Findings
On 3/24/25 at approximately 3:30 PM, a review of R 85's medical record revealed the following, dated 3/21/25, in the progress notes Res (resident) could be heard yelling out/screaming in the hallway and at the nursing station several times thus far in shift.
Several interventions attempted; None effective.
Res calms down when nurse consoles at bedside but soon as this nurse walks out room patient behaviors starts back.
Res tells his roommate to shut up even though roommate doesn't say anything.
Denies any pain or discomfort. NP 1 (Nurse Practitioner) Aware via telephone; Verbal order given for Benadryl 50 mg (milligram) by peg (percutaneous endoscopic gastrostomy tube) every 8 hours prn for 14 days.
Med (medication) administered via peg without difficulty flowing.
Will re-assess behavior LPN (Licensed Practical Nurse) 3 On 3/24/25 at approximately 4:19 PM, R 85 was yelling and the DON (Director of Nursing) stated that had R 85 had an order for Benadryl 50 mg for agitation.
On 3/24/25 at approximately 5:28 PM, during an interview RN (Registered Nurse) 1 confirmed that R 85 had been yelling, that she had tried to calm him down but had administered no medications for yelling.
After reviewing the progress notes, RN 1 confirmed that on 3/21/25 Benadryl 50 mg PRN x 14 days by way of peg tube, a verbal physicians order, taken by LPN 3 did not appear in the EMR (electronic medical record) MAR and that none had been administered.
On 3/24/25 at approximately 5:07 PM, during an interview the DON confirmed her previous statement that there had been a verbal order on 3/21/25 for Benadryl 50 mg PRN.
She reviewed the EMR physician orders and MAR and stated that the order had not been entered or administered, then called NP 1 on 03/24/25 at approximately 5:09 PM. NP 1 confirmed over the telephone that she had ordered Benadryl 50 mg PRN x 14 days on 3/21/25 and still wanted the order to be in place.
The DON stated this physicians order should have been entered as a medication order in the EMR and administered as prescribed.
Review of the facility policy titled Medication Storage last revised [DATE] revealed, Policy: Medications and biologicals are stored safely, securely and properly following manufacturers recommendations or those of the supplier.
Once any medication or biological package is opened, the facility should follow manufacturers guidelines with respect to expiration date of opened medications.
An observation and interview on [DATE] at 9:25 AM of the medication room East Wing with Licensed Practical Nurse (LPN) 4 revealed the following: One unopened bottle of Pink Bismuth Regular Strength 8 fluid ounces with an expiration date of 12/24, one Laboratory Vacutainer blue top with an expiration date of [DATE], two insulin Novolog pens with an expiration date of [DATE] and Lot number MZF3X25 and two boxes of Blood Culture Collection Kits with an expiration date of [DATE] all confirmed by LPN 4.
An observation on [DATE] at 9:40 AM in the Central Supply Room, revealed the following: One box of 12 Tegaderm Dressings with an expiration date of [DATE] lot number (#) 33C893, confirmed by LPN 5 as expired.
During an interview on [DATE] at 9:43 AM, the Central Supply personnel stated, There should not be any expired items in here, I should be checking them, and I try to but don't have the time.
An observation and interview on [DATE] at 9:45 AM of the North Unit Treatment Cart revealed, one unopened Blood Culture Kit with an expiration date of [DATE], LPN 5 confirmed it was expired and said she was going to throw it away.
During an interview on [DATE] at 10:52 AM, the Director of Nursing (DON) stated, Insulin pens are stored in the fridge until open.
The wound supplies should be current, not expired.
There should not be expired meds in the med room or med room refrigerator.
425170 03/26/2025
Calhoun Convalescent Center 601 Dantzler Street Saint Matthews, SC 29135
jeopardy to resident health or safety Using a 2 step process with an approved EPA disinfectant wipe to remove any visible contaminants, soil or other debris and using a second EPA disinfectant wipe to disinfect the device surfaces,
Validating EPA disinfectant is available on their medication cart at the beginning of their shift.
Licensed nurses will be reeducated by the DON on 03/25/2025 on EBP including criteria that required EBP: Resident with an infection or colonization with a multi-drug resistant organism not on transmission based precautions.
Resident with wounds, including pressure, diabetic foot, unhealed surgical and venous wounds.
Residents with an indwelling medical device such as a central line, urinary catheter, feeding tube, tracheostomy, and peripherally inserted central catheters.
Any licensed nurse not receiving this reeducation validation by 03/25/2025 will receive prior to their next scheduled shift.
This will be presented in new hire orientation and in Agency orientation.
The DON will randomly observe 2 licensed nurses for 5 days performing blood glucose monitoring to validate proper procedure including infection control technique and correct glucometer is being utilized.
The DON/Designee will validate each morning for 5 days EPA disinfectant wipes and available on each med cart that stores glucometers.
The DON/Designee will review the facility activity report and 24-hour report in the clinical morning meeting Monday-Friday to identify any resident who require EBP and validate orders are written, provider and responsible party are notified, signage on residents door, PPE is available and care plan updated.
On 03/26/2025 at 4:00 PM the removal plan was accepted.
425170 03/26/2025
Calhoun Convalescent Center 601 Dantzler Street Saint Matthews, SC 29135
Observation on 3/24/25 at 5:50 PM, Licensed Practical Nurse (LPN) 1 was observed placing an Evencare G2 glucometer into a pouch. LPN1 stated she had just finished checking a resident's blood sugar and had cleaned it with an alcohol wipe since all residents have their own glucometer.
During an interview on 3/24/25 at 5:54 PM, LPN2 described how she cleans the Evencare G2 glucometers stating that she uses MicroKill Bleach Wipes even though each resident has their own glucometer.
On 03/24/2025 at 5:55 PM RN1 opened the medication cart.
She opened each pouch and pulled the machine from the pouch to verify who had a glucometer. R168 and R67 did not have a glucometer in their pouches.
When asked if she performed a blood sugar check on either of these residents, she stated, I had to do a blood sugar checks check earlier on R168, around noon. I used R86's blood sugar checks machine for him. I always clean with an alcohol pad, with each person.
His blood sugar was 279.
Record review of R86's Face Sheet revealed she was admitted to the facility on [DATE] with diagnoses including but not limited to type 2 diabetes mellitus, binge eating disorder, and morbid obesity.
Record review of R86's quarterly Minimum Data set (MDS) with an Assessment Reference Date (ARD) of 02/19/25 revealed a Brief Interview Mental Status (BIMS) score of 15, of 15, indicating she was cognitively intact.
Record review of R168's Face Sheet revealed he was admitted on [DATE] with diagnoses including but not limited to: orthopedic aftercare following surgical amputation.
Record review of R168's MDS admission MDS with an ARD date of 03/18/25 revealed a BIMS score of 15, of 15, indicating he was cognitively intact.
Record review of R168's MAR dated 03/24/25 at 12:30 PM indicated that a blood sugar check was performed, with a result of 279 mg/dL.
Record review of R67's Face Sheet revealed R67 was admitted to the facility on [DATE] with the diagnoses including but not limited to: type 2 diabetes mellitus with hyperglycemia, hypertension, pain, and schizophrenia.
Record review of R67's quarterly MDS with an ARD of 03/14/25 revealed a BIMS score of 12 of 15 which indicates he is moderately impaired.
425170
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 425170 B.
Wing 03/26/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Calhoun Convalescent Center 601 Dantzler Street Saint Matthews, SC 29135
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.